Facial Trauma
Joseph Lang, MD
April, 2011
Objectives
• Discuss relevant anatomy and physiology
• Discuss identification and emergent
treatment ocular injuries
• Discuss identification and emergent
treatment of maxillo-facial injuries
• Discuss identification and emergent
treatment of dental and oral injuries
Ocular Injuries
• Eye trauma accounts for 1% of visits to ER
• Often associated with facial fractures
• Approximately 90% of injuries could be
prevented with protective lenses
Mechanisms of Injury
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Burn
Blunt force
Laceration/abrasion
Penetrating Trauma
Assessment
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Determine mechanism of injury
Quick visual acuity
Examine lids and periorbital structures
Neurologic exam
Ocular Burns
• Assess what chemical, bring in bottle if
possible
• Remove contact lens if in place
• Irrigate with saline 1000 cc by drip and
remove any free foreign bodies
Blunt Force
• Fist, ball, heavy object
• Direct trauma to globe – subconjunctival
hemorrhage, globe injury
• Injury to surrounding structures – orbital
wall fractures, nerve injury, muscular
entrapment or hematoma
Blunt Force Management
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Visual acuity
Cardinal movements
Neurologic exam
Do not let pt blow nose
Cover area with saline soaked gauze
Pain management
Laceration/Abrasion
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Corneal layer is only 5-6 cells thick
Abrasions heal in 2 days
Possibility of globe rupture
Usually does not require treatment in field
except removal of loose foreign bodies,
may irrigate in certain situations
Penetrating Trauma
• Visual acuity
• Do not remove any objects in eye,
stabilize area
• Do not touch eye
• We all want to see pictures…
Maxillo-Facial Trauma
• Blunt trauma much more common than
penetrating
• Airway issues of main concern
• Neurologic issues
• Hemorrhage
• Other trauma
Facial bones
Facial Bone Strength
• High impact
– Supraorbital rim: 200 g
– Symphysis mandible: 100 g
– Frontal-glabellar: 100 g
– Angle of mandible: 70 g
• Low impact
– Zygoma: 50 g
– Nasal bone: 30 g
Facial Fractures
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Nasal bone most common
Look for fluid coming from nose (CSF)
Cover area with gauze, ice if available
Control bleeding with compression
Frontal Bone Fracture
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One of the hardest bones to break
Significant trauma
Often associated brain/eye injury
Cover any open areas with saline soaked
gauze
• Trauma center
Orbital Injuries
• Generally refers to structures surrounding
globes
• Need to assess globe and vision
• Check extra ocular motion (EOM)
• Do not let pt blow nose
Zygoma Fractures
• Refers to “cheekbones”
• Zygoma fractures may affect vision, may
also cause numbness on cheek due to
nerve entrapment
• Trismus
Maxillary Fractures
• Classified by Le Fort System
• I – separates hard palate from bone
• II – separates central maxilla and hard
palate from rest of face
• III – craniofacial disassociation – entire
facial skeleton is removed
Maxillary Fractures
• If suspected, can use gentle pull on upper
incisor area
• Often associated with other structures
such as blood vessels, nerve, parotid
glands
• Le Fort III almost always has CSF leak
• Difficult airway
Mandible Fractures
• After nasal bone, most common fracture of
face
• Usually 2 fractures
• Open or closed
• May note malocclusion, numbness,
dislocation
• Look in preauricular area
Mandible Fractures
• Often have dental fractures or subluxed
teeth
• May have significant intra-oral debris
• Airway issues
• Screening test is bite stick test
Mandibular Dislocations
• Usually occur from motion that opens
mouth widely – yawning, vomiting, singing
• May occur from seizure or direct trauma
• Anterior most common
• May be unilateral or bilateral
Pediatrics
• Head is larger in proportion to body than in
adults
• Up to 60% of children with facial fractures
have intracranial injury
• Children more likely to have serious
exsanguination from facial wounds than
adults
Oral Injuries
• Includes dental and tongue injuries
• Penetrating trauma
• Airway issues
Dental Avulsion
• Primary tooth – implantation not done
• Permanent tooth – mechanism, time out of
socket, what tooth was lying in
• Inspect tooth to see if intact
• Inspect site of tooth loss
Dental Avulsion Care
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Do not touch root or scrub tooth
May use gentle saline irrigation
If possible, attempt reimplantation in field
If unable to reimplant in field, place tooth
in transport medium – Hank’s solution,
milk, saline
Dental Fractures
• 85% maxillary teeth
• According to one medical website, lists the
top causes, #6 is ice hockey
Intra-oral Lacerations
• May require suction
• Can cover with saline dressings
• If penetrating trauma, and object still in
place, secure object and transport
Facial Gunshot Wounds
• High mortality, dependant on angle and
bullet
• Bullet may travel in unpredictable pattern
• Airway nightmares
Questions
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